This is Steven Salzberg's blog on genomics, pseudoscience, medical breakthroughs, higher education, and other topics, including skepticism about unscientific medical practices. Here's where I can say what I really think about abuses and distortions of science, wherever I see them.

The federal government is wasting over half a billion dollars a year on chiropractic and osteopathic manipulation

A book on the abuses of chiropractic,
written by a former chiropractor

Here's a quick way for the U.S. government to save over half a billion dollars. Stop paying for coverage of medical procedures that have little or no evidence to support them.

The Centers for Medicare and Medicaid Services (CMS) now releases annual reports of how much it spends, broken down according to the procedures. Their latest data, for the year 2015, reveals that Medicare spent $564,165,721 on pseudoscientific medical practices.

I'm talking about chiropractic and osteopathic manipulation. These are similar but distinct belief systems, both involving bones, and both with little high-quality evidence to back them up. Most people think that chiropractors' spinal "adjustments" can relieve pain from injured or aching backs. It turns out that it's just an elaborate placebo: a back rub at home is likely to work just as well. And that home treatment is probably safer–I'll get to that below.

Osteopathic manipulative therapy (OMT) was invented out of whole cloth in the mid-19th century by Andrew Still. Still believed that every part of the body was linked by a mysterious "myofascial continuity" and that manipulating it could treat a vast range of aches, pains, and other ailments.Most of this is not true. (There is some evidence that OMT can be beneficial in carefully selected cases of lower back pain, but the evidence is quite thin (see this review), and the CMS codes don't distinguish different uses of OMT.)

Osteopathic manipulation is what Larry Nassar, the now-convicted sexual predator, claimed he was doing to the hundreds of young girls whom he molested over the years when he was a sports doctor at Michigan State University and a doctor for the U.S. Olympic gymnastics team. (Osteopathic physicians, which is what Nassar was, generally practice real medicine, and I don't mean to suggest that any of them endorse Nassar's awful abuses. However, OMT is a relic of their pseudoscientific past, and Medicare should not be covering it.)

Chiropractic is no better than OMT. It was invented by D.D. Palmer in the 1890s, around the same time that Andrew Still was concocting OMT. Palmer mistakenly believed that misalignments of the spine, which he called subluxations, caused a vast range of health problems, even infectious diseases. As retired chiropractor Samuel Homola has written,

but thanks to clever marketing, chiropractors have convinced millions of people to see them on a regular basis. (See chirobase.org for much, much more.)

Even more alarming is that chiropractic adjustments carry a small but frightening risk of causing a stroke, as a result of tearing the vertebral artery, as I've written about before. In fact, the American Heart Association issued a warning in 2014 that "neck manipulation may be associated with stroke". Not surprisingly, the chiropractors association strenuously denied this, but the evidence speaks otherwise. Indeed, a 2015 study that I described when it appeared showed that Medicare patients–the same cohort whom we are paying half a billion dollars a year to provide chiropractic treatments–suffered a significantly higher risk of stroke after seeing a chiropractor than those who instead saw a real doctor.

And a 2003 study in the journal Neurology show an equally alarming increased risk of stroke due to tears in the vertebral artery after chiropractic in younger patients. The lead author of that study, Dr. Wade Smith, warned that

"physicians and patients should be aware of spinal manipulation therapy as a rare but potentially causal factor in stroke."

[Update: note that a 2016 study, in the journal Cureus, found that the link between chiropractic neck manipulation and arterial dissection was not causal; i.e., that chiropractic did not appear to cause arterial tears. However, concerns remain, as demonstrated in this 2017 case report of cerebral hemorrhage following chiropractic activator treatment.]

The 2015 numbers from the Centers for Medicare and Medicaid Services show that the vast majority of the wasted funds, $545 million, went to chiropractic treatments, with another $19 million going to osteopathic manipulation. Neither amount is justified by scientific evidence.

Let's stop wasting our money on procedures that don't help, and may harm, Medicare patients. If we want to help patients, let's insist that Medicare spend our money on real medicine.